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Waste Tire Survey & Inspection Repors. Inspection Report Number . <br /> Cal Recycle State of California — <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1226262 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A -SUrvey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: V a 3 [J t ® Routine Q Re-inspection Q Referral O Observation <br /> Local ` If Referral,choose referral type(Fill one) <br /> Identifier: �v.. JC�.�(Q,t/�� v� 0 CHP Q CalRecycle Q Complaint Q Educational Visit 0 Other <br /> Business or Facility Name v Inspected By Inspector <br /> Physical Address Y►Lbl�� <br /> CA '?5.3` Inspection Date <br /> M- G� Time In L Time Out <br /> Business Rep Title ® AM Q AM <br /> I o • a QPM ' t 0 P <br /> �e &an�os rlG-rr, _ <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (? <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 3 <br /> ® Active ® Passenger ® Generator 0 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude — O Planned O OTR �J End-Use 40 Container <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Notice Of Violation 0 Extension <br /> O Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> O Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) N <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <br /> W <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators *In Compliance-No Violations o <br /> O O Other:§ <br /> Comments <br /> 4 <br /> Inspection Form Included: Q <br /> Comments Included: ® . .r l � � 1•-le <br /> siness Rep's Signature Phone Number 41npeeor' SiVre Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: 1EIXIAIMIPLE 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />